Provider Demographics
NPI:1548320179
Name:GREAT ROAD DENTAL ASSOCIATES,P.C
Entity type:Organization
Organization Name:GREAT ROAD DENTAL ASSOCIATES,P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KINAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KANBAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-263-8525
Mailing Address - Street 1:296 GREAT RD
Mailing Address - Street 2:
Mailing Address - City:ACTON
Mailing Address - State:MA
Mailing Address - Zip Code:01720-4710
Mailing Address - Country:US
Mailing Address - Phone:978-263-8525
Mailing Address - Fax:978-263-2955
Practice Address - Street 1:296 GREAT RD
Practice Address - Street 2:
Practice Address - City:ACTON
Practice Address - State:MA
Practice Address - Zip Code:01720-4710
Practice Address - Country:US
Practice Address - Phone:978-263-8525
Practice Address - Fax:978-263-2955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA193361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty